Complication Of Deep Vein Thrombosis Research Articles

Associated Factors Of Post Thrombotic Syndrome In Patients With Deep Vein Thrombosis

Background: Post-thrombotic syndrome (PTS) is a chronic complication of deep vein thrombosis (DVT) which results in decreased quality of life and high health-care costs. Age, gender, obesity, type 2 diabetes mellitus, ipsilateral DVT, history of surgery, use of anticoagulants, and history of malignancy are risk factors that associated with the occurrence of PTS. Method: This case-control study was conducted in 2019 at Sanglah Hospital, Denpasar. The presence or absence of risk factors of patients who met the inclusion criteria would then be obtained from medical records. Univariate, bivariate and multivariate analyzes were performed using SPSS. Results: From 48 patients, 60.5% of the subjects were ≤60 years old and 56.3% were female. In the bivariate analysis it was found that not using anticoagulants (OR: 7.28; 95% CI = 2.03-26.10; p = 0.00), obesity (OR: 26.4; 95% CI = 5.54- 125.7; p = 0.00) and history of surgery (OR: 4.94; 95% CI = 0.92-26.41; p = 0.04) were risk factors associated with the incidence of PTS. Meanwhile, in the multivariate analysis, it was found that obesity status was the most dominant factor in which obese patients had a 31.91-fold higher risk of experiencing PTS (95% CI: 4,623-220.3; p = 0.00). Conclusion: Obesity, not using anticoagulants and history of surgery were factors that were independently associated with the occurrence of PTS in patients with DVT.

What should a general practitioner know about the management of patients with venous thromboembolism?

The era of the Severe Acute Respiratory Syndrome CoronaVirus 2 (SARS-CoV-2) virus has shown that non-core specialists can be involved in the treatment of epidemic diseases. However, the entire burden for the prevention and treatment of venous thromboembolism (VTE) falls on doctors – cardiovascular surgeons, phlebologists. It should be borne in mind that most of the thromboses – more than 2 million cases per year – are asymptomatic, and only a small part has pulmonary embolism, pulmonary hypertension, and death. The survival rate of patients with deep vein thrombosis (DVT) for 8 years is 65 %, with a combination of DVT with pulmonary embolism; the survival rate does not exceed 34 %, so a doctor of any specialty should know how to suspect VTE. The clinical picture of DVT is not always pronounced. Most often, with DVT, patients complain of swelling and pain in the affected lower limb, a decrease in the volume of active movements, and skin cyanosis. Diagnosis of DVT and thromboembolic complications at the non-specialized level should initially consist of assessing the risk of VTE using special scales, among which the Wales scale is of the greatest importance. The gold standard for diagnosing DVT is duplex ultrasound. Among the main indicators for hospitalization is not the fact of the established diagnosis of DVT, but the presence of comorbid pathology, chronic lung diseases, and old age. Additional risk factors include extended DVT, suspected pulmonary embolism, and pregnancy. The goal of anticoagulant therapy is to stop the process of pathological hypercoagulability, the progression of thrombus formation and create conditions for restoring vascular patency, while the pathological idea is that anticoagulants “dissolve the thrombus”. In this regard, anticoagulant therapy is the mainstay of treatment for DVT. To determine the duration of anticoagulant therapy, the etiology of thrombosis is of particular importance – the trigger that led to the formation of thrombotic masses.

Current challenges in the prevention and management of post-thrombotic syndrome-towards improved prevention.

Post-thrombotic syndrome (PTS) is a common and potentially debilitating complication of deep vein thrombosis (DVT), affecting up to 50% of DVT patients. The consequence of this chronic condition includes reduced quality of life, increased use of the healthcare system and decreased productivity. The societal impact of this condition is projected to increase, given our ageing population and increased burden of thrombotic diseases. Despite significant recent advances in our understanding of PTS, many unanswered questions remain. Currently, there are few effective and proven options for established PTS; hence, the emphasis should be on instituting effective prevention to reduce the progression to PTS. Effective anticoagulation lowers the risk of PTS, with direct oral anticoagulants appearing to outperform vitamin-K antagonists. However, the evidence for elastic compression stockings and endovascular thrombolysis or thrombectomy techniques remains unclear. Accurate identification of individuals at high risk of developing PTS may also improve the targeting of preventative interventions. This review will examine the current body of evidence regarding PTS, with a focus on preventative strategies as well as novel biomarkers.

The risk for post-thrombotic syndrome of subjects with deep vein thrombosis in an Indonesian referral hospital: a retrospective cohort study

BackgroundPost-thrombotic syndrome (PTS) is a complication of deep vein thrombosis (DVT) and affects 20–40% of DVT subjects. The risk factor of PTS after DVT is difficult to determine. We aimed to evaluate the incidence of PTS after 3 months of DVT diagnosis and to determine the risk of PTS.MethodsA retrospective cohort study of subjects who developed DVT confirmed by Doppler ultrasound in Cipto Mangunkusumo Hospital from April 2014 until June 2015. The presence of PTS was assessed after 3 months of completed DVT treatment using the Villalta score. Risk factors for PTS were evaluated from medical records.ResultsThere were 91 subjects with DVT with mean age of 58 years. 56% were female. It was dominated by subjects aged ≥ 60 years (45.1%). Hypertension (30.8%) and diabetes mellitus (26.4%) were the major comorbidities in this study. Deep vein thrombosis occurred commonly in unilateral side (79.1%), proximal localization (87.9%), and unprovoked DVT (47.3%). The cumulative incidence of PTS after DVT was 53.8%, 69% of subjects had mild PTS. Heaviness of the leg (63.2%) and edema (77.5%) were the most common symptoms.ResultsThere were 91 subjects with DVT with mean age of 58 years. 56% were female. It was dominated by subjects aged ≥ 60 years (45.1%). Hypertension (30.8%) and diabetes mellitus (26.4%) were the major comorbidities in this study. Deep vein thrombosis occurred commonly in unilateral side (79.1%), proximal localization (87.9%), and unprovoked DVT (47.3%). The cumulative incidence of PTS after DVT was 53.8%, 69% of subjects had mild PTS. Heaviness of the leg (63.2%) and edema (77.5%) were the most common symptoms. Significant risk factors for PTS were unprovoked DVT (adjusted RR 1.67; 95%CI: 1.17–2.04; p = 0.01) and female gender (adjusted RR 1.55; 95%CI: 1.03–1.94; p = 0.04). Age, body mass index, thrombus location, immobilization, malignancy and surgery was not associated with PTS.ConclusionWe conclude that 53.8% of subjects suffered PTS after 3 months of DVT. Unprovoked DVT and female gender were significant risk factors for PTS.

Deep vein thrombosis as a rare complication of scrub typhus

Scrub typhus is a common re-emerging, acute febrile infectious disease, caused by orientia tsutsugamushi, transmitted by bite of chiggers of trombiculid mite. The clinical presentation of infection can vary from mild symptoms to severe multi organ failure, shock, encephalopathy, meningoencephalitis, DIC and various thromboembolic complications. We describe a rare hematological complication of deep vein thrombosis (DVT) caused by scrub typhus in a 61-year-old female. Vasculitis and perivasculitis with endothelial dysfunction could be considered as the main pathologic mechanism causing this complication.

Isolated pulmonary embolism - a specific clinical entity?

Pulmonary embolism in classical meaning is a complication of deep vein thrombosis (usually in the leg veins), developing after a part of the thrombus dislodged and got wedged in pulmonary arteries. However, in half of the patients with pulmonary embolism, deep vein thrombosis is not found. One potential explanation is a different, less common location of the thrombus or previous complete embolization of the whole thrombotic mass. Another possibility is pulmonary artery thrombosis in situ, which is a specific clinical entity associated with some typical risk factors. It develops in the place of vascular injury, as a consequence of hypoxia, inflammatory changes, endothelial dysfunction and injury. Pulmonary artery thrombosis in situ can be a complication after lung resection, radiation therapy, chest trauma, in the patients with Behçet´s disease, sickle cell anemia, chronic obstructive pulmonary disease, tuberculosis or covid pneumonia. Pulmonary artery thrombosis in situ may differ from classical pulmonary embolism in prognosis as well as in therapeutic approach.

Functional impact of pediatric postthrombotic syndrome

BackgroundPostthrombotic syndrome (PTS) is the most common complication of deep vein thrombosis (DVT) in children. ObjectivesWe aimed to assess the impact of pediatric PTS on functioning as assessed by movement ability, mobility, functional disability, and physical activity levels in children after diagnosis of limb DVT. MethodsPatients aged 8-21 years in follow-up care after objectively documented limb DVT were prospectively recruited in this cross-sectional study. Measures of functioning (outcomes) included self-reported questionnaires that assessed: 1) movement ability, measured with the Movement Ability Measure-Computer Adaptive Test version; 2) mobility, evaluated with the Computer Adaptive Test version of the Patient-Reported Outcomes Measurement Information System Pediatric Physical Functioning, Mobility domain; 3) functional disability, evaluated with the Functional Disability Inventory; and 4) physical activity levels, evaluated with the Godin Leisure-Time Exercise Questionnaire. The main predictor was PTS severity, which was assessed using the index for the Clinical Assessment of PTS in children. The association between PTS and outcomes was analyzed using linear models. ResultsEighty-seven patients (median age, 16 years; 25th-75th percentile, 15-18 years; 56% boys) were enrolled. Adjusted for age, sex, and underlying condition, increasing PTS severity was associated with lower current movement ability, a wider gap between current vs preferred movement ability, lower mobility, and slightly higher functional disability scores. There was a nonsignificant effect of PTS severity on moderate-strenuous physical activity. ConclusionIn children, increased PTS severity is associated with lower movement ability and impaired mobility. Reducing the gap between the patients’ current vs preferred movement ability is a relevant aspect of PTS management in children.

Role of statins in the prevention of post-thrombotic syndrome after a deep vein thrombosis event: a systematic review and meta-analysis

BackgroundPost-thrombotic syndrome (PTS) is the most frequent long-term complication of deep vein thrombosis. Apart from anticoagulation, there are no medications, procedures, devices, or lifestyle changes that effectively prevent PTS. There is a growing interest in the potential protective effects of statins for the prevention of PTS. ObjectiveTo conduct a systematic review and meta-analysis on the role of statins to prevent PTS after a DVT event. MethodsWe searched the MEDLINE(R) ALL, Embase, Cochrane Central Register of Controlled Trials, and Scopus from inception to April 5, 2022. The main concepts searched were “statins” and “post thrombotic syndrome.” There was no language restriction. The main outcome measure was the incidence rate ratio (IRR) for PTS associated with exposure to statins. ResultsOf 1971 screened records, 5 studies were included in the meta-analysis (2 retrospective cohorts and 3 randomized controlled trials [RCTs]). The pooled incidence of PTS was 34.8% per patient-year (95% CI, 9.5–127.4) in patients receiving a statin and 41.6% per patient-year (95% CI, 13.2–132) in controls. Exposure to statins was associated with a significantly decreased risk of PTS (IRR, 0.78; 95% CI, 0.63–0.96, I2 = 0%). Meta-analysis of the 2 retrospective cohorts found a significant reduction in the risk of developing PTS (IRR, 0.68; 95% CI, 0.51–0.91), whereas meta-analysis of RCTs showed no reduction in PTS occurrence (IRR, 0.92; 95% CI, 0.68–1.25). ConclusionsAlthough this systematic review suggests that statins may reduce PTS incidence by 22% after deep vein thrombosis, meta-analysis of RCTs showed no risk reduction. Confirmation of the efficacy of statins on the prevention of PTS should be assessed in larger RCTs.

The incidence of deep vein thrombosis after anterior cruciate ligament reconstruction: An analysis using routine ultrasonography of 260 patients.

Recent studies regarding deep vein thrombosis (DVT) after anterior cruciate ligament (ACL) reconstruction investigated only symptomatic complications. The purpose of this study was to assess the true incidence of DVT after ACL reconstruction, regardless of symptom manifestation. Medical records of 260 patients who underwent isolated ACL reconstruction between January 2014 and December 2019 were retrospectively reviewed. Regardless of symptom manifestation, DVT was examined for all patients at 1 week postoperatively using ultrasonography. Demographics, injury mechanism (high energy direct injury and low energy indirect injury), soft tissue injury, preoperative anterior laxity, tourniquet time, and surgical technique (transtibial, anteromedial portal, and outside-in techniques) were investigated. Soft tissue injury was evaluated on magnetic resonance imaging (MRI) scans, based on the Tscherne classification. Risk factors for proximal DVT were identified using logistic regression analyses. A total of 21 (8.1%) patients showed DVT. 5 (1.9%) patients had thrombosis at the popliteal vein; however, none of them exhibited symptoms. The other 16 patients had thrombosis at the distal veins: 1 patient at the anterior tibial vein, 5 patients at the posterior tibial vein, 3 patients at the peroneal vein, 6 patients at the soleal vein, and 1 patient at the muscular branch vein. The risk factors for proximal DVT included high energy direct injury (p = 0.013, odds ratio = 10.62) and grade 2 soft tissue injury (p = 0.039, odds ratio = 6.78). The true incidence of DVT, including symptomatic and asymptomatic complications, were 8.1% after ACL reconstruction. This rate is higher than the previously known incidence which has been investigated only for symptomatic patients. Injury mechanism and soft tissue injury should be assessed when considering thromboprophylaxis.

Prevalence and Associated Factors of Post-Thrombotic Syndrome in Patients With Deep Vein Thrombosis

Background: Post-thrombotic syndrome (PTS) occurs as a long-term complication of deep vein thrombosis (DVT). The aim of this study was to evaluate the prevalence of PTS and its associated factors in a cohort of patients with lower extremity DVT in Sri Lanka. Methods: A descriptive cross-sectional study was conducted in 80 patients who were assessed 6 months to 2 years after the acute episode of DVT. They were assessed using Vilalta scale to diagnose and grade the severity of PTS, anthropometry to calculate body mass index (BMI), duplex ultrasound scans, patients’ clinic record including international normalized ratio (INR) charts and an interviewer administered questionnaire. Categorical data were analyzed using Chi-square test and continuous variables were analyzed using analysis of variance (ANOVA) to determine association. Results: Prevalence of PTS was 45.5% (36/80) according to Villalta scale. Recurrent DVT (P = 0.0002), high BMI (P = 0.073), and previous venous in competence (P = 0.032), showed significant association with PTS. Proximal DVT demonstrated a strong association with PTS (P = 0.002). Residual thrombosis at 3 months was strongly associated with PTS (P < 0.001), however, with a bias of very low sample with repeat duplex at 3 months post event. Awareness of PTS was extremely low (n = 0, 0%). Practice of elastic compression stockings (ECSs) use as a preventative measure of PTS failed to show any significant association (P = 0.61). Conclusions: This study showed a significant prevalence of PTS among patients with previous DVT. Development of PTS is probably multi factorial. A validated risk assessment tool should be used to identify at-risk patients as prevention is the best approach to this irreversible morbidity. J Curr Surg. 2022;12(2):38-44 doi: https://doi.org/10.14740/jcs459

Meta-analyses of sulodexide and other drugs in prevention and treatment of post-thrombotic syndrome.

Post-thrombotic syndrome (PTS) is a common chronic complication of deep vein thrombosis. Elastic compression (ECS) is the common pillar for PTS prevention and treatment, while the pharmacological approach for PTS includes direct oral anticoagulants (DOACs) and venoactive drugs (VADs) for prevention and treatment, respectively. Sulodexide can be used both in long-term prevention and in the treatment of PTS. To better understand the efficacy of the main drugs used in the prevention (sulodexide or DOACs) and treatment of PTS (sulodexide or VADs), pairwise meta-analyses of observational studies and RCTs were conducted. A literature search in MEDLINE, Embase, and Cochrane Library for observational studies and RCTs was performed. Incidence of PTS, reduction in PTS signs or symptoms and proportion of patients with complete venous ulcers healing were the primary outcomes for prevention and treatment of PTS, respectively. Fixed and Random effect model meta-analyses were performed. Heterogeneity and publication bias were assessed. R® software was used for the analysis. 893 articles were identified during the search. 8 observational studies (6 for DOACs and 2 for sulodexide) and 2 RCTs for sulodexide, out of the 11 studies included in the qualitative synthesis, were included for the prevention and treatment of PTS, respectively. Meta-analyses of observational studies showed an overall incidence of PTS of 15% (95% CI, 11-19) for sulodexide, and a 50% reduction of PTS signs and/or symptoms for rivaroxaban compared to warfarin (OR, 0.50; 95% CI, 0.38-0.65). The overall estimate of the two sulodexide RCTs showed a significant improvement in complete ulcer healing, with an OR of 2.32 (95% CI, 1.49-3.63). In prevention of PTS, sulodexide and rivaroxaban showed a low incidence and reduced risk of PTS respectively, while in PTS treatment, sulodexide was significantly effective in the complete ulcers healing. These results confirm the need to move from the traditional single-pillar approach with elastic compression stockings to a more effective multi-pillar approach, tailoring the treatment to each individual patient.

Lower strength stockings: is less better?

Post-thrombotic syndrome is a common complication of deep vein thrombosis characterised by chronic tiredness of the leg, cramps and leg pain in combination with oedema and irreversible skin changes, and ultimately venous ulceration of the leg.1 Treatment options are scarce and consist of immediate anticoagulation therapy to prevent thrombus propagation, and elastic compression stockings with the potential to enhance recanalization, and reduce the onset of post-thrombotic changes.2,3 More invasive strategies such as catheter directed thrombolysis have been studied, but combined results of the three most recent trials were disappointing.

Comparison of the Effects of Injectable Enoxaparin With Oral Rivaroxaban in Deep Vein Thrombotic Prophylaxis in Patients With Femoral Peritrochanteric Fracture: A Randomized Clinical Trial

Objectives: The prevalence of deep vein thrombosis (DVT) following orthopedic major surgery, such as peritrochanteric femoral fracture, is high. Also, there is a lack of accurate information about the results of using rivaroxaban in Iran. This study aimed to compare the effects of injectable enoxaparin with oral rivaroxaban in DVT prophylaxis in patients with femoral peritrochanteric fracture. Materials and Methods: This randomized single-blind clinical trial included 88 patients with femoral peritrochanteric fracture in Shohada Hospital of Tabriz, Iran from January 2019 to December 2019. The participants were randomly allocated into two equal groups (n=44 each) receiving enoxaparin (40 mg subcutaneously once daily for 28 days) and rivaroxaban (10 mg orally once daily for 28 days). Using independent t test in SPSS version 20, the results of clinical examinations and ultrasonography for the diagnosis of DVT at the end of intervention were compared between the two groups. A P value less than 0.05 was considered as statistically significant. Results: No significant differences were observed in laboratory results and DVT-related symptoms between the two groups, as well as before and after the intervention (intragroup). Also, the prevalence of DVT at the end of the study was zero. Conclusions: According to our results, there was no difference in the prevalence of DVT and short-term (one-month) complications between the two groups receiving rivaroxaban and enoxaparin after the peritrochanteric femur fracture.

How to optimize the prevention of post‑thrombotic syndrome: recent advances.

Post‑thrombotic syndrome (PTS) is the most frequent complication of deep vein thrombosis, and it can be detrimental to the quality of life of the affected patients. Once affected by this chronic condition, the patient's treatment options are very limited, so preventive therapies are crucial. Currently, the prevention of PTS is hampered by the lack of unequivocally effective therapies. However, improved insight into pathogenesis of this condition acquired in recent years, including the central role of residual venous obstruction, could lead to a better application of existing therapies and identification of novel therapeutic targets. Plausible therapeutic agents include flavonoids and statins, while promising future agents include those that target leukocyte‑endothelial interaction. Moreover, differences in PTS risk were found to be partly explained by a tendency of patients to form clots that are less susceptible to lysis. Finally, identifying patients that are expected to benefit most from certain therapies is equally valuable for the success of future preventive strategies. This requires exploration of better risk stratification through machine learning techniques.

Study on Litigation-expertise of Sudden Pulmonary Embolism for Laparoscopic Inguinal Hernia — Case Report and Literature Review

With the development of new concepts and technologies of laparoscopic diagnosis and treatment, inguinal hernia repair is increasingly and widely used in clinical practice, and accordingly, the corresponding complications of deep vein thrombosis have also attracted clinical attention. Deep-venous thrombosis and pulmonary embolism have become one of the potential and very dangerous serious complications in patients with inguinal hernia. One case of sudden pulmonary embolism shortly after the laparoscopic inguinal hernia repair was reported in this paper, the patient has been trapped in a persistent plant survival state after rescue. The patient was a male, 67-year-old patient with up to 4 hours of operation, and no available clinical evidences about operative vascular injury have been found, however, this case have been triggered a civil lawsuit for medical damages and the filing of a judicial expertise. Combined with the disputes of this case and the results of the technical review, the legal related preoperative notification and informed consent, the requirements and functions of working system before operation, the preoperative examination and the related surgical risk-factors of pulmonary embolism are discussed. It is suggests that the preoperative discussion, preoperative examination and preoperative notification of laparoscopic inguinal hernia should be paid great attention to in clinical work, and form an institutionalized and normative workflow, which plays an important role in effectively controlling the operation time, reducing surgical complications and avoiding medical disputes.

Role of coagulation profile in prevention of bleeding complications in primary total knee arthroplasty patients

Introduction: Incidence of deep vein thrombosis (DVT) (1.9%-3%) and pulmonary embolism (PE) (0.01%) post total knee arthroplasty (TKA) in Asian population is less compared to western population (85% and 1.5%-10% respectively). Hence, routine chemoprophylaxis following Western protocols is debatable in Asia. Wound complications like bleeding, hematoma, blisters, skin necrosis are high with low molecular weight heparin (LMWH) as compared with Aspirin. Aspirin is associated with low rate of DVT and PE (0.008% - 0.35%). The aim is to study the coagulation profile and adverse events like DVT, PE and wound complications in postoperative TKA patients on pharmacological DVT prophylaxis and watch for correlation between coagulation parameters and bleeding complications, and accordingly administer thromboprophylactic agents. Methods: Prospective observational study. 463 patients undergoing primary unilateral TKA were bifurcated into groups according to thromboprophylaxis given by two surgeons. 1. 271 patients received LMWH 2. 192 patients received Aspirin Patients were evaluated with coagulation profile preoperatively and postoperatively and observed for wound complications, DVT and PE. Results: The use of LMWH conferred a significantly higher incidence of wound soakage (p

Coagulopathy and related complications following sclerotherapy of congenital venous malformations.

Congenital venous malformations (VMs) are low-flow vascular anomalies that can cause coagulation abnormalities. This phenomenon, referred to as localized intravascular coagulopathy (LIC), is characterized by elevated D-dimer, hypofibrinogenemia, and/or thrombocytopenia. Increased risk for LIC includes patients with an extensive VM, multifocal VM, and Klippel-Trenaunay and CLOVES syndromes. Peri-procedural anticoagulation has been given to prevent complications from LIC in patients undergoing surgical/interventional procedures; however, the rate of clinically relevant complications from sclerotherapy is largely unknown. The purpose of this study is to describe a single-institution's incidence of LIC in patients with VMs and coagulopathy-related complications following sclerotherapy. Retrospective chart review of patients, 0-21years of age, with VM who underwent sclerotherapy without peri-procedural anticoagulation and had coagulation profiles evaluated within 1month prior to sclerotherapy. diagnosis type (high vs. low risk for LIC), coagulation profile (including PT/PTT, D-dimer, fibrinogen, and platelet count), sclerosant used, and post-procedure outcomes. Coagulopathy-related complications included clinically relevant bleeding, deep vein thrombosis (DVT), and pulmonary embolism (PE). N=138 patients; 59.4% were female. The most common location of VM was the lower extremity (47.8%; 66/138). Of patients with high-risk VMs (29/138 [21%]), 11/29 (37.9%) had laboratory values consistent with LIC, whereas 5% (5/109) of low-risk VMs had LIC. In sum, 492 sclerotherapy procedures were performed with no complications of bleeding, DVT, or PE. Patients undergoing sclerotherapy for VM with abnormal coagulation profiles may not require peri-procedural low molecular weight heparin (LMWH). Further studies are needed to precisely define which patients would benefit from anticoagulation.

The Post-thrombotic Syndrome-Prevention and Treatment: VAS-European Independent Foundation in Angiology/Vascular Medicine Position Paper.

ImportanceThe post-thrombotic syndrome (PTS) is the most common long-term complication of deep vein thrombosis (DVT), occurring in up to 40–50% of cases. There are limited evidence-based approaches for PTS clinical management.ObjectiveTo provide an expert consensus for PTS diagnosis, prevention, and treatment.Evidence-ReviewMEDLINE, Cochrane Database review, and GOOGLE SCHOLAR were searched with the terms “post-thrombotic syndrome” and “post-phlebitic syndrome” used in titles and abstracts up to September 2020.Filters WereEnglish, Controlled Clinical Trial / Systematic Review / Meta-Analysis / Guideline. The relevant literature regarding PTS diagnosis, prevention and treatment was reviewed and summarized by the evidence synthesis team. On the basis of this review, a panel of 15 practicing angiology/vascular medicine specialists assessed the appropriateness of several items regarding PTS management on a Likert-9 point scale, according to the RAND/UCLA method, with a two-round modified Delphi method.FindingsThe panelists rated the following as appropriate for diagnosis: 1-the Villalta scale; 2- pre-existing venous insufficiency evaluation; 3-assessment 3–6 months after diagnosis of iliofemoral or femoro-popliteal DVT, and afterwards periodically, according to a personalized schedule depending on the presence or absence of clinically relevant PTS. The items rated as appropriate for symptom relief and prevention were: 1- graduated compression stockings (GCS) or elastic bandages for symptomatic relief in acute DVT, either iliofemoral, popliteal or calf; 2-thigh-length GCS (30–40 mmHg at the ankle) after ilio-femoral DVT; 3- knee-length GCS (30–40 mmHg at the ankle) after popliteal DVT; 4-GCS for different length of times according to the severity of periodically assessed PTS; 5-catheter-directed thrombolysis, with or without mechanical thrombectomy, in patients with iliofemoral obstruction, severe symptoms, and low risk of bleeding. The items rated as appropriate for treatment were: 1- thigh-length GCS (30–40 mmHg at the ankle) after iliofemoral DVT; 2-compression therapy for ulcer treatment; 3- exercise training. The role of endovascular treatment (angioplasty and/or stenting) was rated as uncertain, but it could be considered for severe PTS only in case of stenosis or occlusion above the inguinal ligament, followed by oral anticoagulation.Conclusions and RelevanceThis position paper can help practicing clinicians in PTS management.

DEEP VEIN THROMBOSIS – A SYSTEMATIC REVIEW

Deep vein thrombosis (DVT) is the formation of blood clots in deep veins, commonly the leg veins and the pelvic veins. DVT is a potentially fatal condition leading to increased mortality and morbidity if not diagnosed and treated promptly.Incidence is more prevalent in 60- 65 years of age because of increased pro-coagulant factors like factor VIII, factor VII, homocysteine, brinogen. With the increase in age the risk of DVT development increases exponentially.All bed ridden patients should receive sequential compression device therapy as primary DVT prophylaxis in the form of intermittent pneumatic compression device (IPCDs), graduated compression stocking (GCS), and the venous foot pump.The pharmacological agents used in the prophylaxis of DVT include low-molecular-weight heparins (LMWH), fondaparinux, Unfractionated heparin (UFH), new oral direct selective thrombin inhibitors and factor Xa inhibitors.The complications of DVT include development of Pulmonary embolism (PE) , Paradoxical emboli, Recurrent DVT, Post thrombotic syndrome. Approximately 4% individuals treated for DVT develop PE. It accounts for 10-12% mortality rate in hospitalized patients.The prevention and treatment must be upgraded continuously with evidence base strategies. This article aims at reviewing the clinical presentation, diagnostic and treatment modalities of DVT

Thromboembolic complication among COVID-19 patients in the intensive care unit (ICU): a single-centre study from a Malaysian perspective

Funding AcknowledgementsType of funding sources: None.IntroductionThe emerging complications of thromboembolism (TE) in COVID-19 patients have led to severe consequence such as death. Nonetheless, the prevalence of TE complications among COVID-19 patients in the Intensive Care Unit (ICU) in Malaysia is unknown.ObjectiveTo investigate the prevalence of thromboembolic (TE) complications including venous [deep vein thrombosis (DVT), pulmonary embolism (PE), and line related thrombosis] and arterial [stroke, peripheral arterial disease and myocardial infarction (MI)] thrombosis and mortality among COVID-19 patients admitted to an ICU at a single centre hospital. The proportions of patients with TE complication who died, and factors associated with the occurrence of thrombotic complications were explored.MethodsIn this retrospective Malaysian cohort study, patients admitted to a single centre ICU with PCR confirmed of SARS-CoV-2 virus and received adequate thromboprophylaxis within February 2020-2021 were included. Thromboembolic (TE) event is a combination of venous and arterial thrombosis.ResultsMean (SD) age 56.6 (13.7), 63.5% were male, 61.6% Malays, median (IQR) 7 (3-14) days of ICU admission, 64.2%, 53.2% and 20.9% had underlying hypertension, diabetes and obesity respectively. Of 534 patients, 4 (0.7%) developed DVT, 198 (37.1%) PE and 2 (0.4%) line related thrombosis. Meanwhile, 21 (3.9%) developed stroke, 39 (7.3%) MI, 1(0.2%) PAD and 22.8% died despite adequate thromboprophylaxis. In total, 240 (44.9%) developed TE event during their ICU admission. Significantly higher proportions of COVID-19 patients who developed complications of DVT (2.5% vs. 0.2%; p = 0.013), PE (47.5% vs 34.0%; p = 0.006), stroke (12.3% vs. 1.5; p < 0.001) and MI (16.4% vs. 4.6%; p < 0.001) died. Age, duration of ICU admission, obesity, white cell count (WCC), troponin, D-Dimer and corticosteroid use were significantly greater among those with TE events. Demographics, co-morbidities, other laboratory parameters and inflammatory markers were similar in COVID-19 patients with and without TE events. Predictors of TE events on multivariate logistic regression analysis were age [OR 1.02 (95% CI 1.00-1.03)], obesity [OR 2.84 (95% CI 1.93-4.18)], WCC [OR 1.04 (95% CI 1.00-1.07)], and duration of ICU admission [OR 1.04 (95% CI 1.02-1.06)].ConclusionIn this cohort of severely ill COVID-19 patients, the overall prevalence of TE complication was high (44.9%) with the overall mortality of 22.8% despite adequate thromboprophylaxis. Key predictors of TE events included age, obesity, white cell count, and duration of ICU admission. Perhaps a more aggressive treatment (combination of thromboprophylaxis and enhanced anti-inflammatory treatment) may be needed among COVID-19 patients admitted to ICU with high risk factors to prevent further increase in the incidence of thromboembolism and death.